Provider Demographics
NPI:1528404795
Name:PEACH TREE DENTAL HOLDINGS, LLC
Entity Type:Organization
Organization Name:PEACH TREE DENTAL HOLDINGS, LLC
Other - Org Name:PEACH TREE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:HENTON
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-255-9440
Mailing Address - Street 1:702 N TRENTON ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3324
Mailing Address - Country:US
Mailing Address - Phone:318-255-9440
Mailing Address - Fax:318-251-1270
Practice Address - Street 1:702 N TRENTON ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3324
Practice Address - Country:US
Practice Address - Phone:318-255-9440
Practice Address - Fax:318-251-1270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA52051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty